197606676-12-13-2023-31-AS-NRED-CYGPPH-20231213102935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606676
Report Date: 12/13/2023
Date Signed: 12/13/2023 10:30:03 AM

Document Has Been Signed on 12/13/2023 10:30 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BROOKDALE GARDENS OF TARZANA		FACILITY NUMBER:	197606676
ADMINISTRATOR:	HELEN LEE		FACILITY TYPE:	740
ADDRESS:	18700 BURBANK BLVD		TELEPHONE:	(818) 342-0003
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	90	CENSUS: 57	DATE:	12/13/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Amanda Monroy		TIME COMPLETED:	10:30 AM

NARRATIVE

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At 9:45 a.m. on 12/13/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the executive director and disclosed the reason for the visit.

Today’s case management visit was conducted after the Woodland Hills-South Adult and Senior Care Regional Office received a report and an SOC341 from the facility of a staff member, Staff #1 (S1), handling Resident #1 (R1) in a rough manner. The Executive Director sent the reports at approximately 3:00 p.m. on 12/06/2023 after reviewing video footage of the incident. The reports detailed that at approximately 12:30 p.m. on 12/02/2023, S1 was pushing R1 in their wheelchair. R1 told S1 they did not want to go to the bathroom and planted their feet. S1 continued to push R1 and R1 fell forward. The facility evaluated R1 for injuries and no injuries have been reported.

Today, LPA interviewed the executive director at 9:50 a.m., the health and wellness coordinator at 9:55 a.m., reviewed video footage of the incident at 10:00 a.m., toured the facility at 10:05 a.m., and reviewed records including but not limited to R1’s emergency contact list, medical assessment, service plan, and S1’s employee file. LPA was unable to interview R1 at 10:15 a.m. due to a prior engagement.

The executive director informed the LPA that S1 is currently suspended from working at the facility. The facility is conducting an internal investigation and LAPD have an ongoing investigation. Due to the need for more information, LPA will return at a future date to resolve the matter.

No immediate health and safety hazards were observed during this visit.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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